Signs and Symptoms

Generally a fairly featureless headache

The pain is typically bilateral, pressing or tightening in quality and of mild to moderate intensity, and it does not worsen with routine physical activity. No more than one of photophobia, phonophobia or mild nausea and neither moderate or severe nausea nor vomiting

Exclusion of other causes of headache (can be done clinically)

A scan is not generally considered necessary.

Note:

Featureless headaches can also be caused by structural problems, so keep clinical antennae raised.

For acute treatment:

a) Consider Aspirin, Paracetamol or an NSAID for the acute treatment of tension-type headache taking into account the person's preference, comorbidities and risk of adverse events.

• Paracetamol 1g every four to six hours as required, maximum dose 4g/24 hours.
• Aspirin 900mg
• Ibuprofen 400mg 3-4 times daily or naproxen 500mg bd should be considered as first line for NSAID therapy.

Do not offer opioids for the acute treatment of tension-type headache.

For prophylactic treatment:

a) Consider a course of up to 10 sessions of acupuncture over 5-8 weeks for the prophylactic treatment of chronic tension-type headache (not available on NHS)

b) Tricyclics are commonly recommended by neurologists, but there is no robust evidence from randomised clinical trials.

• Dosulepin (unlicensed) 25mg to increase every two weeks in 25mg doses to 150mg maximum dose.
• Amitriptyline (unlicensed) initially 10mg at night, increased if necessary to maintenance of 50-75mg at night; maximum 150mg at night.

Other considerations:

a) Consider the diagnosis of Medication Overuse Headache. Determine whether the patient has been taking simple analgesics (prescribed and/or OTC) on 15 or more days a month, or codeine-containing analgesics, ergot or triptans on 10 or more days a month. If so, these drugs should be stopped (warn patients of temporarily exacerbating headache) and the headache re-assessed 4 weeks later.

b) Consider anxiety/depression and lifestyle factors – these are often important. Treat as necessary.

Referral Criteria

Generally tension type headache causes little disability and treatment/referral to neurology/headache clinic is not usually required

Evidence

References: NICE Clinical guideline CG150: Headaches: diagnosis and management of headaches in young people and adults

Pathway Group

This guideline has been signed off on behalf of NHS Devon.

Author: S Weatherby, Consultant Neurologist, PHNT / Dr G Lenden Clinical lead DRSS Western

Publication date: January 2017